Health data standards and systems

Could you please assist with clarifying the indexing of HIV and the advice in ACS 0102 HIV/AIDS?

We have a patient with bacterial pneumonia on a background of HIV. If I follow the index and look up HIV, the index says 'see also Human/Immunodeficiency virus (HIV) disease'. The default code when I go here is B24. I could also potentially go to the subterm 'resulting in, bacterial infection NEC' B20. But on reviewing the patient history they do not appear to have HIV disease although the term 'asymptomatic' is not used.

To get to Z21 do I have to have the words 'asymptomatic status' documented, as this is an essential modifier?

I don't believe that ACS 0102 is very clear about differentiating between the use of Z21 and B24. It also states if the patient presents to hospital with a condition not related to the HIV infection and there is unclear documentation relating to the patient's current HIV status, to check with the clinician as to the stage of the disease. How do we know if the condition is related or not, do we need a documented link or do we go by known manifestations of HIV such as PCP or Kaposi's sarcoma? Even if the link is there, is it because the condition is a manifestation/AIDS defining illness, or because the patient has a suppressed immune system?

If coders within our team are inconsistent in assigning these codes, then it would imply that there is ambiguity in the index and ACS.


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Retired advice that is quite helpful - 10AM Commandments Vol 9 Number 1 June 2002:

HIV/AIDS coding…some helpful reminders ACS 0102; B20–B24
Documentation of HIV status should always be coded even if the criteria for an additional diagnosis are not met. This instruction has been added to ACS 0102 HIV/AIDS in ICD-10-AM Third Edition.
Ensure the appropriate stage of HIV disease is being coded. Once a B20-24 Human immunodeficiency virus (HIV) disease code is used, you cannot go back to using Z21 Asymptomatic HIV infection status.
Hint: Consult the whole record.
Information in previous episodes of care should be taken into account.
Use two (or more) codes to fully reflect the condition. Ensure the codes are sequenced according to the guidelines in Australian Coding Standard 0102 HIV/AIDS.
Take particular care in sequencing dagger and asterisk codes.
Hint: Index entry:
Pneumonia
- pneumocystis (carinii) B59† J17.3*
- - resulting from HIV disease B20

Three codes are assigned. The B20-B24 code should be assigned, as well as the codes for the pneumocystis.
Use Z29.2 Other prophylactic therapy as principal diagnosis (and sequence the HIV status code second) where a potential manifestation is being treated prophylactically and is not a current condition – for example, nebuliser treatment for a potential respiratory problem.
Hint: To ward off opportunistic infection, prophylactic treatment may be initiated when T-cell counts fall. As the infection has not yet occurred, or is not current, the manifestation should not be coded.
Clarify with the clinician if it is unclear whether the presenting condition is associated with the HIV disease. Test results such as antibodies, viral loads, or T-cell counts may provide an indication of disease progression. These should be interpreted by the clinician.
Hint: Even if the condition is clearly not a manifestation of HIV, remember to still code the HIV status as an additional code. If a B20-B24 code has been previously assigned then B24 Unspecified HIV disease must be used (and not Z21 Asymptomatic HIV infection status).

Australian Coding Standards Introduction, section titled Documentation within the health care record, paragraph 6 states ’Some clinical coders and CDIS may possess a medical, nursing or allied health degree, but cannot diagnose patient conditions, as they are not a designated member of the clinical team treating the patient’. Therefore, clinical coders are not to determine if the condition is related to HIV, except in the following circumstances:

1. There is a documented link between the condition and HIV
For coding purposes, a documented link could mean the conditon is a manifestation of HIV or an AIDS defining illness.

VICC has obtained clinical advice that ‘HIV-related’ and ‘AIDS-defining’ are not mutually exclusive terms. All AIDS defining illnesses could be referred to as HIV related. That is AIDS defining illness is a subset of HIV-related illness.

Look for documentation in the current episode of care and past episodes, referral letters, emergency and/or outpatient notes. This is supported by: IHPA Coding Rule TN1505: ACS 0010 Clinical documentation and general abstraction guidelines – Abstraction from outside the episode of care which states:
‘A Clinical Coder should only be looking outside of the current episode of care (e.g. past episodes, referral letters, emergency and/or outpatient notes) only when conditions documented in the current episode of care require further clarification or specificity, or where the reason for admission is required (e.g. from outpatient notes or referral letters)’.

Therefore, if HIV is documented in the current episode of care, it is appropriate to review past episodes, referral letters, emergency and/or outpatient notes to obtain details of the patient’s HIV status, and if the patient has documented manifestations of HIV.

2. If there is documentation in the current episode of care or in past episodes, referral letters, emergency and/or outpatient notes that the patient has or had Kaposi sarcoma. Kaposi sarcoma is the only condition that is referenced in ACS 0102 HIV/AIDS (Human immunodeficiency virus/acquired immune deficiency syndrome) as a manifestation of HIV (section titled Manifestations and other related conditions, Kaposi Sarcoma).

3. Clarification has been sought via a clinical documentation query as to the appropriate status of the disease or if the condition was a manifestation of the patient’s HIV.

In the example cited of bacterial pneumonia on a background of HIV, as per VICC 3207 Conditions noted to be “on a background of…”, the term ‘on a background of’ does not qualify as a relationship or manifestation between the condition and HIV. There is also no further specificity of the HIV status. Therefore assign:
J15.9 Bacterial pneumonia, unspecified following Index entry Pneumonia (acute) (double) (migratory) (purulent) (septic) (unresolved)/bacterial and Z21 Asymptomatic human immunodeficiency virus [HIV] infection status in accordance with ACS 0102, ‘asymptomatic HIV status’ section.

There is no advice in ACS 0102, that requires the term 'asymptomatic’ to be specifically documented to be able to assign Z21 Asymptomatic human immunodeficiency virus [HIV] infection status. VICC notes there are Index entries that lead to Z21 that do not require the term ‘asymptomatic’.

4. The condition is a complication of HIV or of treatment
Clinical advice obtained by VICC indicates that bacterial pneumonia (specifically pneumococcal pneumonia) is more likely to develop in someone with HIV due to the immunosuppression induced by HIV. The HIV is not directly causing bacterial pneumonia (HIV is a virus), but it is’ weakening the immune system and therefore increasing the probability of getting sick enough to need to come to hospital, from bacterial pneumonia’. Therefore, immunosuppression is not considered to be a manifestation of HIV.

ACS 0102 section titled Antiviral therapy complications or adverse effects states ‘Antiretroviral therapy can result in complicating conditions such as anaemia, neuropathy and urinary tract calculi’. A condition that is documented as a complication of treatment is not considered to be a manifestation of HIV.

VICC recognises the standard is not in keeping with the current clinical knowledge, and is aware that a public submission to review ACS 0102 HIV/ AIDS is currently in progress.